. INTRODUCTION Sex, Disease, and Medicine The most remarkable change in patterns of health during the last century has been the largely successful conquest of infectious disease. Less than one hundred years ago diphtheria, tuberculosis, pneumonia, typhoid, and dysentery consti- tuted this nation’s greatest health threats; epidemics could devastate a city or town with tragic speed. In 1918 an outbreak of Spanish influenza claimed more victims than did combat in World War 1.’ Today these diseases are largely un- der control if not virtually unknown. Although there is considerable debate about the reasons for the decline of these infections-some credit medical advances while others have stressed a rising standard of living, better nutrition, and nat- ural changes in the host-parasite relationshipthere is no doubt that we have much less to fear from infectious disease than we did even a generation ago.* Yet, strikingly, venereal diseases are inadequately controlled, if controlled at all. Given the power of the contemporary media, it seems impossible to be un- aware of the current problem. Herpes, a viral infection that is often transmitted sexually, is according to most reports epidemic, affecting perhaps as many as 20 million Americans. With no effective treatments available, it threatens to become endemic. Even more ominous is the new disease known as Acquired Immune Deficiency Syndrome (AIDS). Found primarily among homosexual males, in most cases this disease poses a lethal threat. Again, there is no known effective treatment. Yet even syphilis and gonorrhea, diseases for which cures have been developed, remain in dramatically high proportions. Gonorrhea constitutes the most prevalent bacterial infection on earth, with over one hundred million cases occurring annually; more than two million of which occur in the United States.’ Why, if we have been successful in fighting infectious disease in this century, have we been unable to deal effectively with venereal disease? To answer this question, we must examine venereal disease not only as a biological entity, but as a disease that has engaged certain attitudes and values; beliefs about its causes and consequences that in turn affect responses to the problem. A society’s response to those who are ill, its employment of medical discoveries and resources, is closely related to its most basic assumptions and 3 4 NO MAGIC BULLET belief^.^ I have attempted, therefore, to trace shifting attitudes and perceptions concerning venereal disease among both laypeople and physicians during the last century. In addition, I have sought to evaluate the impact of these beliefs and values upon medical practice, public health and military programs, and social behavior in general. Although no single agency regulates sexuality-social reformers, families, and public institutions, as well as popular culture, all exert influence in this area- in the twentieth century, Americans increasingly turned to physicians for ad- vice, counsel, and treatment for sexual diseases and problems. Physicians throughout the last hundred years have presented divergent views concerning the meaning of venereal diseases and approaches to their control. Recent stud- ies have rightly cautioned against seeing the medical profession as a monolithic entity.5 Yet despite disagreement and internal debate among doctors, the de- bate over venereal disease increasingly took place within professional circles, rather than between professionals and laypeople. Contention among physicians did not call into question their essential authority in sexual matters. But the response to venereal disease was not always limited to private ex- changes in the doctor’s office; in the twentieth century there have been major public interventions that provide the central focus for this study. As the costs of venereal disease became clear, both public health and military officials sought to address the problem of these infections, transforming a previously secreted medical issue into a social dilemma. Their public pronouncements and poli- cies-from municipal ordinances requiring doctors to report cases to authorities to military orders calling for compulsory chastity-reflected prevailing views of the problem at various historical moments. To what extent were the responses of physicians, public health officials, and the military to venereal disease deter- mined by social values, sexual concerns, and scientific advances? Because of my concern with the relationship of scientific and medical advances to social attitudes and professional practice regarding venereal disease, this study begins in the last decades of the nineteenth century, when researchers made the first dramatic breakthroughs concerning the specific causative agents of the venereal diseases. The social history of venereal disease reveals major trends in the develop- ment of modern medicine. Perhaps more than any other single theme, twen- tieth-century medicine has been characterized by the search for ‘‘magic bullets”-specific treatments to root out and destroy infecting microorganisms. This biomedical model has come to define the role ,and nature of the medical enterprise. In this paradigm, individuals become infected with a parasite that causes dysfunction of some sort; disease is defined as a deviation from a biolog- ical norm.6 Social conditions, environmental phenomena, and other variables are generally discounted as causes of disease. The physician dispenses “magic bullets” that restore the patient to health. This book suggests that this paradigm is too restrictive; to find the solution to problems of disease we must look be- yond, the model of the magic bullet. Although I have been concerned with professional and institutional issues, I have attempted to link these activities to social definitions of venereal diseases. INTRODUCTION 5 This focus on disease as it is socially defined forces a reorientation in historical approach, a different set of priorities; the frame of reference is expanded beyond the narrower field of clinical medicine. This study, therefore, directs attention to various “social constructions” of venereal diseade particular symbols which American society came to associate with these diseases and their victims. By ’ assessing the symbols and images which diseases attract we can come to under- stand the complex phenomena of illness. The symbols reflect social values- patterns of judgment about what is good or bad that guide perceptions and practice. They tell us how a disease is regarded, how we believe it is caused, who its victims are, and what they are like. Some diseases are viewed as the result of a sinister environment beyond our control; others are blamed on the individual victim and his or her personality and behavior.’ Examining these constructions can help us to recover the values at the core of medicine, and to make decisions about their meaning for the medical task. Our ability to rec- ognize and interpret these symbols substantiallyaffects medical practice and public health. Fundamental to the notion that disease is socially constructed is the premise that it is profoundly shaped by both biological and cultutal variables. Attitudes and values concerning disease affect the perception of its pattern of transmis- sion, its epidemiological nature. Only if we understand the way disease is in- fluenced by social and cultural forces-issues of class, race, ethnicity, and gender-an we effectively address its biological dimension. A “social construc- tion” reveals tacit values, it becomes a symbol for ordering and explaining as- pects of the human experience. In this light, medicine is not just affected by social, economic, and political variables-it is embedded in them. Since the late nineteenth century, venereal disease has been used as a sym- bol for a society characterized by a corrupt sexuality. Venereal disease has typ- ically been used as a symbol of pollution and contamination, and cited as a sign of deep-seated sexual disorder, a literalization of what was perceived to be a decaying social order.* Venereal disease makes clear the persistent association of disease with dirt and uncleanliness as well, revealing pervasive cultural atti- tudes and values. We have known since the late nineteenth century that venereal diseases are caused by microorganisms, and yet the persistent association of dirt and disease is remarkable. The very term which the venereal disease control movement took for itself in the hventieth century-social hygiene-makes ex- plicit this association. Within the social constructions of venereal disease in the last century a num- ber of important values have been expressed; themes that reflect longstanding historical traditions regarding sexual behavior.’ In particular, venereal disease came to be seen as an affliction of those who willfully violated the moral code, a punishment for sexual irresponsibility. These infections were employed to ar- gue for a more restricted sexuality. So long as these social uses of the diseases have dominated medical and public approaches, therapeutic approaches to the problem have necessarily remained secondary. Because of the nature of these diseases, individuals often have suffered a double jeopardy: the physiological consequences of the disease itself, as well as the deep psychological stigma. 6 NO MAGIC BULLET Venereal disease provided evidence for those seeking to demonstrate-for a variety of reasons-that attempts to regulate sexuality had failed, that the ideal- ized unified social values of American society